Provider Demographics
NPI:1386077360
Name:SPANN, SALLY (PA)
Entity type:Individual
Prefix:
First Name:SALLY
Middle Name:
Last Name:SPANN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11803 SOUTH FREEWAY
Mailing Address - Street 2:
Mailing Address - City:BURLESON
Mailing Address - State:TX
Mailing Address - Zip Code:76028
Mailing Address - Country:US
Mailing Address - Phone:817-551-7553
Mailing Address - Fax:
Practice Address - Street 1:11803 SOUTH FWY
Practice Address - Street 2:SUITE 110
Practice Address - City:BURLESON
Practice Address - State:TX
Practice Address - Zip Code:76028-7012
Practice Address - Country:US
Practice Address - Phone:817-551-7332
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-14
Last Update Date:2013-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical